RN/LVN (Utilization Management Nurse)

Job Description

A rapidly expanding healthcare management organization is seeking an experienced RN or LVN with strong background in utilization management, authorizations, and hospital denial reviews. This role supports insurance-side clinical operations and requires deep familiarity with California insurance regulations, utilization management standards, and HMO/Medicare Advantage processes. The ideal candidate has 3–5 years of experience in UM or case management, understands authorization workflows, and is comfortable overseeing departmental processes. Candidates based in Fresno, CA are preferred; however, remote applicants with strong knowledge of California insurance regulations who can work PST hours will also be considered.

Responsibilities:

• Review, prepare, and process prior authorizations, concurrent reviews, and clinical documentation requests in alignment with California insurance regulations.
• Evaluate and write up hospital denial reviews, appeals, and reconsiderations with strong clinical justification.
• Oversee daily workflows and support operational efficiency within the utilization management team.
• Ensure all UM activities comply with state laws, payer requirements, and organizational policies.
• Collaborate with hospitals, providers, case managers, and internal teams to ensure timely and accurate determinations.
• Maintain thorough documentation of clinical decisions, rationale, and regulatory compliance.
• Serve as a resource for UM policies, California regulatory updates, and utilization management standards.
• Participate in departmental quality improvement efforts and process optimization.
• Communicate professionally with providers, health plans, and internal stakeholders regarding authorizations and determinations.
• Other duties as assigned.

Requirements:

• Active RN or LVN license in the state of California.
• 3–5 years of experience in utilization management, authorizations, case management, or hospital review.
• Strong experience writing and evaluating authorizations, denials, and appeals.
• Thorough understanding of California insurance laws, HMO requirements, and Medicare/Medicare Advantage guidelines.
• Ability to oversee departmental workflows and support UM staff.
• Excellent written communication, clinical documentation, and review skills.
• Strong knowledge of medical terminology, clinical guidelines, and payer criteria.
• Proficiency with EMR/UM software platforms and Microsoft Office tools.
• Preferred: Fresno-based; remote applicants with CA insurance expertise and PST availability welcome.